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Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS)

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Introduction and hypothesis

There seems to be a temporal association between increasing use of “hands off” the perineum in labour and reduced use of episiotomy with an increasing rate of anal sphincter injuries. We aimed to determine how common the practice of “hands off” the perineum is.


An observational postal questionnaire study of 1,000 midwives in England in which the main objective was to obtain an estimate of the number of midwives practising either “hands on” or “hands off” was conducted.


Six hundred and seven questionnaires were returned; 299 (49.3%, 95% CI 45.2–53.3%) midwives prefer the “hands-off” method. Less-experienced midwives were more likely to prefer the “hands off” (72% vs. 41.4%, p < 0.001). A higher proportion of midwives in the “hands-off” group would never do an episiotomy (37.1% vs. 24.4%, p = 0.001) for indications other than fetal distress.


The “hands off” the perineum technique is prevalent in the management of labour. We hypothesise that a possible consequence might be an increased incidence of obstetric anal sphincter injury.

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We thank all the midwives who participated in the survey and Paula Brockman and Angela King for their help with data input.

Details of ethics approval

Approval for the study was sought and obtained from the Plymouth Hospitals NHS Trust R&D Department, who deemed it exempt from Ethics Committee approval.


The study was funded by the Plymouth Urogynaecology Research Fund.

Conflict of interest

RM Freeman is editor of the International Urogynecology Journal and Lead for the Peninsula Collaboration for Leadership in Applied Health Research and Care (PenCLAHRC). M Waterfield and R Trochez have no conflict of interest to declare.

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Correspondence to Ruben Trochez.

Appendix 1

Appendix 1

Survey of the management of the perineum during vaginal delivery

figure a


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Trochez, R., Waterfield, M. & Freeman, R.M. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J 22, 1279–1285 (2011).

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